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Flu shot compliance ­varies among hospital, ­non-­hospital, and EMS employees

Flu shot compliance ­varies among hospital, ­non-­hospital, and EMS employees

It's that time of year again, when infection preventionists (IP) and safety officers begin to plan their ­annual employee flu shot campaign.

For many facilities, the challenges of improving compliance rates remain the same. Despite the typical approaches of making the vaccine free and readily ­available, IPs and safety officers still face cultural roadblocks and misperceptions surrounding influenza vaccination.

At the same time, many facilities have transitioned to a mandatory policy that requires all healthcare employees to get vaccinated as a condition of employment, with provisions for medical contraindications and religious reasons.

Three studies published this year have collected data evaluating compliance rates among hospital healthcare workers (HCW), non-hospital HCWs (outpatient and clinics), and EMS ­workers in the St. Louis region ­during the 2009-2010 and 2010-2011 flu seasons. The studies also looked at H1N1 vaccine compliance during the 2009 outbreak when the H1N1 was a separate vaccination.

In general, the studies highlight areas of ­educational focus in terms of healthcare worker fears and misconceptions, as well as definitive data that shows a mandatory policy drastically improves compliance, says Terri ­Rebmann, PhD, RN, CIC, associate professor at the Institute for Biosecurity at the Saint Louis University School of Public Health and lead author of all three studies.

"The take-home message would be to try and ­implement a mandatory vaccination policy," Rebmann says. "If you can't do that, at least encourage vaccine and do an education campaign that addresses major gaps or ­major issues related to attitudes about the vaccine in hopes that that will increase your compliance."


Looking at the numbers

The following statistics gathered from the three ­studies offer a look at the variance between ­hospital, non-hospital, and EMS workers, and give safety ­officers a glimpse into the reasons why ­healthcare workers have been resistant to the seasonal and H1N1 vaccine.

The study published in the March issue of ­Infection Control and Hospital Epidemiology compared ­seasonal influenza vaccine compliance among hospital and non-hospital HCWs:

  • Vaccine compliance was highest in the 2010-2011 season, with 78.9% of all HCWs getting vaccinated.
  • 75.5% of HCWs said they planned to receive the 2011-2012 vaccine, while 13.8% said they would not receive the vaccine. Hospital-based HCWs were ­significantly more likely to report intent to ­receive the vaccine compared with non-hospital-based HWCs.
  • Hospital-based HCWs were also more likely to receive the vaccine free of charge (93.7%) and to be offered the vaccine on-site (92.7%) compared to non-hospital HCWs (81.3% and 70.8%).
  • Less than a third of HCWs reported their facility had a mandatory flu shot policy, but 51% of those ­respondents were from the hospital setting, whereas 12.5% were from the non-hospital setting.


The most recent study, published in the July ­issue of Infection Control and Hospital Epidemiology, evaluated H1N1 influenza compliance in 2009:

  • 63.3% of the respondents reported getting the H1N1 vaccine; hospital-based HCWs were ­significantly more likely to get the vaccine (74.3%) compared to non-hospital HCWs (53.9%)
  • HCWs who provided direct, face-to-face patient care were more likely to get the vaccine compared to those with no patient contact, and those HCWs who received the seasonal vaccine were much more likely to receive the H1N1 vaccine
  • Only 20.4% of HCWs reported their facility had a mandatory policy for H1N1 vaccination, but 76.3% of those were from hospitals compared to 23.7% in ­non-hospital settings


The study published in the April issue of the American Journal of Infection Control focused specifically on seasonal and H1N1 vaccine compliance among EMS workers in 2009-2010 and 2010-2011:

  • Compliance for the seasonal vaccine was highest during the 2010-2011 flu season, with 73.6% of respondents receiving the vaccine; 71.2% said they planned on receiving the seasonal vaccine in 2011-2012
  • Only 65.5% of respondents received the H1N1 ­vaccine in the 2009-2010 season
  • Only 2.8% of respondents indicated their employer had a mandatory vaccination policy
  • 53.7% of those that did not have mandatory policies were highly encouraged to receive the 2010-2011 seasonal vaccine, 36% were informed about it but not encouraged, and 10.3% indicated they were ­neither encouraged nor informed

Evaluating attitudes and perceptions

One of the big takeaways from all three studies was how HCWs in each sector perceived the seasonal and H1N1 vaccinations. There is still a lot of fear and ­misinformation surrounding the seasonal vaccine, ­particularly among non-hospital HCWs.

For example, only 79.5% of non-hospital HCWs believe they can play a role in transmission if not vaccinated, and 10.7% indicated their immune system was built up so they were not likely to get influenza.

Perceptions among EMS workers were even more telling: Less than three-quarters believe seasonal influenza is a serious disease that can cause death, and just 67.7% said it is important to be vaccinated every year. Only 55.1% said they trust public health authorities when they say the influenza vaccine is safe, and only 69.5% believe they can play a role in transmission if they aren't vaccinated.

It's important to note that EMS workers are employed by third-party vendors, and many are often volunteers, which makes education and enforcement by hospitals much more difficult.

However, the wide popularity of these false perceptions highlight important areas that safety officers and IPs can focus on. Statistics also indicated that encouraging employees to get vaccinated and making the vaccine free and easily accessible were significant ­factors in improving compliance.

More emphasis also needs to be placed on the ­science behind influenza, including the fact that it is a proven method to protect patients, says Ruth Carrico, PhD, RN, FSHEA, CIC, associate professor and clinical ­director of the Vaccine and International Travel Center in the ­Division of Infectious Diseases at the University of ­Louisville School of Medicine.

"The only thing we can do consistently to prevent influenza is be immunized," Carrico says. "So if we know our responsibility is to protect the patient, clearly this should not even be a discussion. This should be ­something every healthcare worker does."

In addition to making seasonal vaccines free and readily available to staff members, hospitals and ­clinics need to emphasize the patient safety aspect, which is often correlated with improving the ­facility's overall culture of safety.

When HCWs ­believe that ­vaccination and patient safety are important to administrators and managers, they often begin to see the benefits.

"If there have been any approaches that have worked, it's that push from administration and from leadership that it's an expected part of the patient safety culture," Carrico says. "You need to share information at the time of hire regarding the expectation for patient safety. It is definitely reflective of the culture of safety and value of patient safety, as opposed to risk management."


Transitioning toward a mandatory policy

More and more facilities are transitioning toward incorporating seasonal vaccines as a condition of ­employment. According to the data collected in her surveys, Rebmann says that hospital workers who have a mandatory policy at their facility are 32 times more ­likely to receive the vaccine compared to those who don't have a mandatory policy.

Also, non-hospital-based workers are 21 times more likely to be vaccinated if they have a mandatory policy.

Although some facilities have been initially hesitant in creating this mandate, there is already clear precedent in requiring vaccines as a condition of employment in healthcare. For those that have exhausted every other approach, a required policy may be the next logical step.

"They already mandate the hepatitis B vaccination, so the question is: Why hepatitis B and not influenza?" Rebmann says. "It just doesn't make sense. That's one of the arguments that healthcare facilities have made."

For years healthcare facilities have tried to ­convince HCWs to get vaccinated every year, only to get compliance rates that top out around 60% or 70%. Facilities that have implemented mandatory policies are setting the bar with 90% compliance or higher, ­proving that it may be the only way to convince those final holdouts.

"We have tried making immunization optional," Carrico says. "We tried and it only goes so far. We have dealt with all of the 'can't' issues, meaning we've made it accessible, it's free in most places, and it's taken directly to the individual. We've dealt with a lot of the issues of, 'We can't get it' or 'It wasn't available,' but now we have to deal with people that just won't."

Rebmann points to the guidelines from the ­Society for Healthcare Epidemiology of America (SHEA) ­issued in 2010 that recommend all healthcare ­facilities ­implement a policy in which influenza vaccination is a condition of employment. Although some ­hospital ­systems have included their clinics and outpatient ­facilities in their mandatory policy, many independently owned facilities have not followed suit.

"I think that's very interesting because the hospitals are taking it to heart," Rebmann says. "I'm not sure if the non-hospital facilities aren't aware of the recommendations, or maybe they think the SHEA recommendations only apply to hospitals."


In 1995, the University of Louisville School of ­Medicine set up the first drive-thru flu shot clinic in the ­country, says Ruth Carrico, PhD, RN, FSHEA, CIC, associate ­professor and clinical director of the Vaccine and International ­Travel Center in the Division of Infectious Diseases at the ­University of Louisville School of Medicine. It was ­originally ­organized to provide vaccinations to those who were ­medically immobile, but over the years it has grown and many health systems use it as an opportunity to vaccinate the public.

According to Carrico, hospitals should think about two main considerations when organizing this event: location and staffing.

"Make sure you have a location that is easy to access, and then think about your workforce and who is going to get that done," she says.

Carrico authored a toolkit on organizing drive-thru ­clinics, including a timeline with talking points to help ­facilities prepare throughout the year. You can access the full toolkit at